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Sir,

A case of conjunctival necrosis and bleb leakage secondary to an adherent conjunctival foreign body is presented.

Case Report

A 72-year-old gentleman presented to ophthalmic causality complaining of irritation watering photophobia, and fall of vision in his left eye for 7 days. He was known to have open-angle glaucoma and had undergone a trabeculectomy to both eyes 5 years ago. There was no history of trauma.

His best-corrected visual acuity was 6/5 in the right and 6/12 in the left eye. There was a cystic conjunctival bleb superiorly in the right eye. A foreign body was adherent to the conjunctival bleb in his left eye. The anterior chamber was shallow and Seidl's test was positive (Figure 1). The intraocular pressure was 2 mmHg. Removal of the foreign body with refashioning of the conjunctival flap was performed under local anaesthesia. The adherent foreign body along with the necrotic tissue was sent for histopathology. Histology showed a seed husk with an underlying granulation tissue. On the first postoperative day, his visual acuity was 6/9 in the left eye, a deep anterior chamber, and an intraocular pressure of 12 mmHg.

Figure 1
figure 1

Photograph showing an embedded foreign body.

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The patient was seen in the clinic 4 weeks following surgery when his visual acuity was 6/6-2 in the left eye with a well-formed conjunctival bleb. His anterior chamber remained deep with an intraocular pressure of 18 mmHg (Figure 2).

Figure 2
figure 2

A deep anterior chamber following removal of foreign body and repair.

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Discussion

Trabeculectomy is the surgical procedure of choice in patients with uncontrolled glaucoma. It is however known to be associated with a number of early and late complications. The most frequently encountered early complications are hyphaema, shallow anterior chamber, hypotony, wound leak, and choroidal detachment. Late complications include bleb leak, cataract, visual loss, and an encapsulated bleb.1

Spontaneous bleb leak may be due to late-onset transconjunctival oozing or a point leak of aqueous humour.2 The risk of late-onset focal bleb leakage increases following trabeculectomy with Mitomycin C therapy.3 Bleb leaks may in turn be associated with chronic ocular hypotony, decreased visual acuity, infection, hypotony maculopathy, corneal oedema with folds, choroidal effusion, and a persistently shallow anterior chamber, which may require intervention.4

Bleb leaks can be managed conservatively or surgically. Nonincisional conservative management is by aqueous suppression with lubrication or patching, bandage contact lenses, cyanoacrylate glue, or autologus blood injection. Surgical techniques are conjunctival suturing, resuturing of trabeculectomy flap, bleb revision with autologous or donor scleral grafting, bleb excision, conjunctival advancement, lyodura, and tenons patching.5 Surgical bleb revision has a high success rate with regard to maintaining a functioning bleb and to preserving vision. When compared with nonincisional treatment, patients with late bleb leaks managed with conjunctival advancement are more likely to have successful outcomes.6

The case in discussion developed a bleb leak secondary to retained foreign body, adherent to the conjunctiva. Formation of foreign body granuloma and associated release of cytokines7 lead to tissue necrosis and consequent bleb leak. This presentation of a retained conjunctival foreign body with conjunctival necrosis and bleb leak is very unusual and to the best of our knowledge has not been reported before.